Many studies of effective teachers address traits rather than behaviors [5, 6]. The literature identifies the following positive traits of effective teachers: approachability, enthusiasm, content expertise, good communication skills, sensitivity to different supervisory needs, and willingness to take the time to teach [5, 8, 9]. While most of these traits transcend cultural barriers, there are subtle variations, and success as a teacher ultimately depends on how these personal traits manifest in a locally relevant practice. But how does one use content expertise to get the most out of a teaching point? And how exactly does one take the time to teach when, seemingly, there is barely time for patient care? Good ED teachers recognize which of their strengths are conducive to effective teaching and actively adapt teaching strategies to both their environment and circumstances. From an international perspective, we recognize that EM is practiced in various physical plant settings, with different patient populations, learner groups, hierarchies, and teaching expectations. However, in the following sections, we detail a number of generalizable strategies for ED teaching and describe how they can be implemented using either of the two integrative models.

A teacher’s impression, or “diagnosis,” of a learner is informed by the learner’s strengths and limitations, the teacher’s experience with the learner, and, in some cases, the knowledge about the learner’s previous performance. The diagnosis represents the learner’s cognitive and behavioral level and contributes to the decision regarding a course of action for advancing the learner’s education. Obvious areas of concern or deficiencies should be noted by the teacher, and any behaviors that are causing significant concern should be identified. The teacher can then make a decision about how to interact with the learner, what should be taught, and what degree of autonomy is warranted.

Learners who are slow to decide on a disposition or overly conservative may be averse to risk. They should be encouraged to make decisions and commit to a course of action within the security of a supervised environment. Some learners are “minimizers” and others are “worriers.” Teachers should adapt their vigilance accordingly. Learners may avoid certain patients because they reveal deficiencies in their skill set. They should be encouraged to face their limitations head-on, with guidance or tools being provided by the teacher. Some learners have specific deficits in core competencies, such as diagnostic reasoning, communication skills, teamwork ability, resource management, professionalism, or critical appraisal. Astute teachers will be vigilant for these deficits and will tailor their approach to address them through teaching and feedback. Learners should be aware of, and ideally agree with, the areas that need focus. Clearly, teachers who are effective at discussing expectations will have the least difficulty with learner diagnosis.

Setup

Learners often require sensitization to learning points or guidance around the approach to a specific patient. This can be accomplished with a brief setup discussion. Careful setup teaches the learner what is important in a given presentation, provides specific guidelines relevant to a patient encounter, and alerts them to the teaching that will follow. For rudimentary or familiar presentations, many learners can engage patients appropriately on their own with little or no setup.

Setup may include medical decision making: “This patient has right upper-quadrant abdominal pain. What are the five most important diagnoses you are going to consider?” or “This patient has chest pain. I want you to bring the ECG to me within 5 minutes if it is anything but normal. Reducing time to acute MI treatment is one of the biggest impacts we can make in emergency medicine.” or “This patient seems to have multiple complaints. Your job is to identify the principle complaint and the chronic problems and determine if any of them seems dangerous. Be clear with the patient about the conditions that we will and won’t be able to address today.”

In some cases, feedback provided for one case will set up the next. For example, if a student requires an inordinately long time to assess a straightforward ankle inversion, a teacher might use feedback about this to set up the next case: “I expect you to complete the history and examination in less than 15 minutes. If it seems it will take longer, I want you to come and tell me and then we’ll figure out why.” A habit of this type of difficulty could have been identified during discussions of expectations and would inform the teacher’s diagnosis of the learner. Consistency through all phases of the teaching model can lead to very satisfying improvements in learner performance.

Some setup issues may pertain to departmental logistics: “Our ultrasound department closes in 30 minutes, so decide in the next 10 minutes if you think this patient will require an ultrasound. That’s a patient flow tip I picked up a few years ago!” Still others may relate to key resources: “This pocket card is a clinical decision rule that I use for patients like this. Go see the patient, then have a look at it. Your job is to tell me if you think he satisfies the components of the rule.” Sensitize the learner to some of these efficiency measures by framing them as learning or practice “tips.”

Teach a Focused Teaching Point

Excellent teachers do not necessarily teach the most. Rather, they teach high-yield material, relate it specifically to an individual learner, and make learning interactive and fun. Selecting an appropriate teaching point is an art. Good teaching points are (i) relevant to the learner (based on expectations, the learner’s diagnosis, and possibly an appropriate setup), (ii) contextual (learned in the course of patient care), (iii) linked to knowledge (based on past encounters with the learner and the knowledge of his or her experiences), and (iv) clearly identified as grounded in evidence, general opinion, or the teacher’s experience. Thankfully, learners do not expect long, thorough reviews of topics in the ED. They appreciate helpful guidance around patient care, “rules of thumb,” useful resources, correction of inaccuracies or deficiencies in their knowledge base, and useful approaches to problems [14]. Many good teaching points pertain to nonclinical issues such as good teaching practice, patient flow, or interprofessional relations.

Good teachers actively seek teaching opportunities. They listen to conversations learners have with each other and other health professionals. They read what learners chart and seek interesting laboratory and imaging results. They summon all learners in the department for a brief teaching encounter around a great case, modified to each learner’s level. Good teachers have a repository of resources that they use to support a teaching point or address a learner’s declared learning need; examples include a digital image library, a file of interesting ECGs or laboratory results, or favorite websites and practice guidelines. For advanced residents, involving them in administrative decisions, diverting nurses’ queries to them, and having triage personnel notify them first about trauma or resuscitation cases all provide important opportunities.

Learners like to be challenged in a safe teaching environment. Success depends directly on proper learner diagnosis and preparing learners for the challenge by setting proper expectations. Rather than focusing on what learners already know or what they can read in a textbook, good teachers promote active learning in three key ways. First, they quickly push learners to the limit of their knowledge and take them to the next step but rarely beyond. Asking for innovative differentials is a good way to do this: “List six extraperitoneal causes of abdominal pain” or “What seven life-threatening thoracic injuries must be sought in the primary survey of a trauma patient?” Good teachers expand on a case: “Okay. It sounds like you know what to do with this patient, but how would that change if she were pregnant?” or “Do you know which patient population was used to derive and validate that decision rule?”

Learners appreciate flexibility in the approach to patients. It is essential that learners be forced to make decisions. As long as their proposal is safe, it is sometimes useful to allow them to carry out their plan even if it is not the teacher’s first choice of action. The learner can then adapt his or her approach through an iterative process by seeing the consequences of decisions. At the very least, learners should be forced to make a commitment and justify their opinion before the teacher explains why a different course of action should be taken.

Effective teachers have strategies for busy times. They acknowledge that detailed teaching will be replaced with more concise case-based teaching focused on learner needs. For example, if ECGs or radiographs have revealed an area of concern, then teaching can focus on any electrocardiographic or imaging studies that have been completed. Rather than teaching the approach to a patient who has had a decreased level of consciousness for 30–45 min, teachers can focus on laboratory results such as acid–base “rules” or a differential diagnosis for an elevated anion gap. The learner can then be referred to a textbook or a website to find an algorithm. The teacher can pose a “theme of the day” such as the differential diagnosis of headache. In available moments, the learner can be prompted for an addition to their list, and the teacher can commit to discussing the pertinent physical findings or investigations for every new item the learner adds. Finishing off the list can then become homework or a topic of discussion after the shift. Likewise, if a learner has difficulty deciding on investigations but has decent assessment skills, the teacher can quickly determine that the story is adequate (by either asking the learner some brief questions or going in to see the patient with the learner in tow) and then focus on teaching the investigations. For example, it would be more useful to focus on the limitations of ultrasound in diagnosing appendicitis than on the embryology of gut rotation and why the appendix is in the right lower quadrant. For a medical student, an introductory line might be, “Walk me through how you examined the abdomen. I’ve got a couple of tricks you may find useful. Then I’ll tell you how I investigate these problems.”For an advanced resident, the focus may be the following: “I talked briefly with the patient you saw, and I agree it sounds like it might be a pulmonary embolism. What do you know about the sensitivity of CT in the diagnosis?” Efficient teachers multitask by “teaching and doing” such as by “talking through” procedures for the benefit of learners.

Good teaching points can be overlooked. Simply telling a learner that the Ottawa ankle rule and where to find it is a useful 30-s teaching point. Going through the rule and its applications is quite another approach, taking perhaps 5 or 10 min. Good teachers recognize the difference between these two approaches and adapt their approach to the time available. Another quick example for the student who has difficulty organizing a differential diagnosis is to provide a mnemonic that they can use for all subsequent cases, and insist that they use it.

Finally, many excellent teachers make use of teaching scripts, described by Irby [14]. Teaching scripts are discrete packages of information that a teacher keeps in the back of his or her mind for common scenarios. Typically, the script is based on the teacher’s experience with other learners at a similar level and focuses on common areas of misconception or difficulty. The beauty of teaching scripts is that they are brief, targeted to common areas of need, and easy to deliver because the teacher is familiar with them. They can be delivered with minimal preparation.

Assess and Give Feedback

Good teachers provide both ongoing and summative feedback to learners. Feedback given in the course of case review can be used to set up future cases: “The most important thing that you write in the chart is the discharge instructions. Please be specific about what you tell patients when they leave. I’ll be looking for this in the next few charts you do.” There is no better time to provide feedback about an incident than shortly after it has occurred, assuming the learner is receptive. In the rare situation in which a particularly stressful or negative event has occurred, feedback should be deferred. Learners should be given either guidance as they progress through the shift or, at the very least, a summary of feedback, including specific references to important incidents, both good and bad, that occurred that day. The use of shift feedback cards is a good way to stimulate and document feedback sessions. See Chapter 7 for a more thorough discussion of this important topic.

A Teacher Always: Being A Role Model

Much of the learning that occurs in the ED is implicit: learners observe what teachers say and do. Learners are frustrated when teachers do something they advised against or if they omit an action that they told the learner is necessary. It is thus important that teachers hold themselves to a high standard and display the behaviors and professionalism they expect from students. Teachers should acknowledge when a statement is their opinion and not an unequivocal truth. Learners might have seen a different approach in the recent past and therefore be confused about contradictions in practice.

Learners must be skilled at identifying their limits. Teachers should also acknowledge when they do not know factual material or require additional expertise to manage a patient. This is seen by good teachers as an opportunity to team up with the learner to solve the problem: “You look here and I’ll look there and we’ll compare notes.” This can also be turned into a homework assignment: “Look this up and see what you find. I’ll do the same, and we’ll talk about it the next time we meet.” Teachers should demonstrate appropriate collaborative behavior with other health professionals and physician colleagues and acknowledge when circumstances lead to suboptimal interactions on busy or frustrating days. Teachers should acknowledge their own learning opportunities: “I learned something today” or “I’ll definitely do that differently next time!”

Multiple strategies for effective ED teaching are discussed in this chapter based on the five microskills delineated by Neher and colleagues and the ED STAT! model [7]. In the ED STAT! structure, the first two steps, that is, setting expectations and diagnosing the learner, taken upon the first meeting of the teacher and student, establish rapport and help develop an effective, efficient learning plan. The next steps are applicable to most teaching encounters: a setup, selection of a key teaching point, assessment, and feedback. Finally, teachers should do what they say and say what they do—they are always teaching through role modeling.

It is not necessary to change all teaching behaviors at once. Teaching can improve even with some incremental positive changes. Learners benefit most from teachers who have the learners’ best interests in mind, are proactive, and are willing to change how they do things in pursuit of better learning and clinical care. In international settings, effective ED teaching requires adaptation to the specific learning environment, with regard to physical space, learner experiences, and sensitivity to cultural issues, in order to maximize teaching effectiveness. Despite its challenges, the teaching of EM can be intensely gratifying. The desire to share knowledge and expertise is a defining feature of our specialty. Our residencies are full of trainees eager to learn, and our responsibility to train them is enormous. We hope the pearls and pitfalls offered in this chapter will help you take advantage of the rich teaching environment in which we are privileged to practice.